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Tarr JT, Coomer CL, Kim SY, Ng M. Overnight to Outpatient: A Single Institution's Experience With Mastectomy and Reconstruction Before and After the Start of the COVID-19 Pandemic. Ann Plast Surg 2024; 93:43-47. [PMID: 38885164 DOI: 10.1097/sap.0000000000003922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
PURPOSE Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential component of this is deciding whether patients need hospital admission following elective procedures. The aim of this study is to investigate operative factors and patient outcomes when mastectomies with or without reconstruction are performed as ambulatory procedures versus planned inpatient admissions. METHODS Patient charts for those undergoing mastectomy with or without reconstruction were retrospectively analyzed ranging from March 2019 until February 2021. Factors such as demographic information, operative type, operating room time, cancer stage, total stay time in the medical environment, and postoperative complications were assessed and compared between the 2 groups. RESULTS A total of 89 patient charts were reviewed, 46 from before the COVID-19 pandemic and 43 from after the start of the pandemic. No differences were observed in demographic factors between the 2 groups. After surgical cases resumed a significant proportion, 79%, of mastectomies with or without reconstruction were performed in the ambulatory center, versus just 2% pre-COVID-19. Similarly, of all of these cases performed, only 19% resulted in hospital admission versus the previous rate of 100% (P < 0.00001). Together, these changes resulted in a significant reduction in length of stay of 39.77 ± 19.2 hours pre-COVID-19 versus 14.81 ± 18.4 hours afterward (P < 0.00001). Unfortunately, a higher number of patients who received surgery after the start of the pandemic elected to forego immediate reconstruction 49% versus 72% (P = 0.032). Most importantly, there were no observable differences found in 7-day readmission, reoperation, or emergency department visit between groups. There was also no difference in 30-day complication rate between groups. CONCLUSIONS Mastectomy with or without reconstruction can be safely performed in the ambulatory setting without additional risk of complications or negative patient factors. This divergence from traditional the protocol of inpatient overnight admission may contribute positively toward patient comfort, minimize the use of healthcare costs and resources, and allow for increased scheduling flexibility for patient and provider alike.
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Affiliation(s)
- Joseph T Tarr
- From the Northwell Health, Division of Plastic and Reconstructive Surgery, Great Neck, NY
| | - Cynara L Coomer
- Texas Health Harris Methodist Fort Worth City, Fort Worth, TX
| | - Sara Y Kim
- Scripps Clinical Medical Group, La Jolla, CA
| | - Marilyn Ng
- Northwell Health, Division of Plastic and Reconstructive Surgery, Staten Island, NY
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Tyner TE, Freysteinson WM, Evans SC, Woo J. "My body, my choice": A qualitative study of women's mastectomy with flat closure experiences. Body Image 2023; 46:419-433. [PMID: 37573764 DOI: 10.1016/j.bodyim.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023]
Abstract
This qualitative study aimed to describe and explore the pre and post-mastectomy experiences of women choosing flat closure after a breast cancer diagnosis. Aesthetic flat closure creates a flat contoured chest wall after a mastectomy. There is limited research on women's flat closure experiences. To fill this gap, we interviewed 19 women (Mage = 53, range 31-72) with breast cancer who underwent a bilateral mastectomy with flat closure, examining decision-making, mirror-viewing, and flat closure experiences. Using a hermeneutic phenomenological design, we generated seven themes. Broadly, women choosing flat closure experienced pressure from their clinicians to undergo breast reconstruction. We found flat closure information to be consistently lacking. Mirror-viewing experiences of women obtaining suboptimal flat closure outcomes led to shattered expectations, mirror avoidance, psychological distress, and body image disturbances. Women negotiated their new reality by discovering ways to feel comfortable with their flat bodies. Regardless of surgical outcome, decision satisfaction was high. These findings illustrate the importance of bodily autonomy and supportive healthcare environments for women making flat closure decisions. Providing comprehensive information on all surgical options and addressing post-operative expectations can improve women's decision-making and mirror-viewing experiences and assist women in adapting to their new body image.
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Affiliation(s)
- Tracy E Tyner
- College of Nursing, Texas Woman's University, P.O. Box 425498, ASB 216, Denton, TX 76204-5498, USA.
| | - Wyona M Freysteinson
- Nelda C. Stark College of Nursing, Texas Woman's University, 6700 Fannin Street, Houston, TX 77030-2897, USA
| | - Stephanie C Evans
- Houston J. and Florence A. Doswell College of Nursing, Texas Woman's University, 5500 Southwestern Medical Avenue, Dallas, TX 75235-7299, USA
| | - Jennifer Woo
- Houston J. and Florence A. Doswell College of Nursing, Texas Woman's University, 5500 Southwestern Medical Avenue, Dallas, TX 75235-7299, USA
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Brantley RA, Thuman J, Hudson T, Gregoski MJ, Scomacao I, Herrera FA. Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database. Ann Plast Surg 2023; 90:S395-S402. [PMID: 37332211 PMCID: PMC11177554 DOI: 10.1097/sap.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.
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Affiliation(s)
| | - Jenna Thuman
- Division of Plastic Surgery, Medical University of South Carolina
| | - Todd Hudson
- College of Medicine, Medical University of South Carolina
| | - Mathew J. Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Isis Scomacao
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
| | - Fernando A. Herrera
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
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Tyner TE, Freysteinson WM. The mirror viewing experience of women undergoing a mastectomy: An integrative review. J Adv Nurs 2023; 79:2081-2097. [PMID: 36876727 DOI: 10.1111/jan.15574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/16/2022] [Accepted: 01/20/2023] [Indexed: 03/07/2023]
Abstract
AIMS To appraise the current literature on the mirror viewing experience of women undergoing a mastectomy. DESIGN Whittemore and Knafl's approach to integrative reviews, Braun and Clarke's thematic analysis, and PRISMA guidelines were utilized for this review. DATA SOURCES A systematic search of primary peer-reviewed articles from April 2012 to 2022 was conducted using PubMed, CINAHL, Academic Search Complete and Google Scholar databases. REVIEW METHODS Eighteen studies met the inclusion criteria (15 qualitative and 3 quantitative) and were appraised using the Johns Hopkins evidence-based practice appraisal instrument. RESULTS Five themes describing the mirror viewing experience were revealed: Mirror viewing motives, mirror viewing preparedness, mirror viewing experience, mirror comfort/avoidance and women's mirror viewing recommendations. CONCLUSION The review findings were found to align with Freysteinson's Neurocognitive Mirror Viewing Model highlighting the occurrence of short-term memory disruptions and an autonomic nervous system response that can lead women to experience a flight/fright or faint response, mirror trauma and mirror avoidance when looking at themselves in the mirror after a mastectomy. IMPACT Women reported feeling unprepared to look at themselves in the mirror, with some experiencing shock and emotional distress, which led to mirror avoidance behaviours as a way to cope with their new body image. Nursing interventions aimed at improving women's mirror viewing experiences may help mitigate this autonomic nervous system response and minimize mirror trauma and mirror avoidance. Preparing women to view themselves in the mirror for the first time may help reduce psychological distress and body image disturbances in women undergoing a mastectomy. NO PATIENT OR PUBLIC CONTRIBUTION This integrative review did not involve patient or public contributions. The authors reviewed currently published peer-reviewed literature in writing this manuscript.
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Affiliation(s)
- Tracy E Tyner
- College of Nursing, Texas Woman's University, Denton, Texas, USA
| | - Wyona M Freysteinson
- Nelda C. Stark College of Nursing, Texas Woman's University, Houston, Texas, USA
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Regional anaesthesia: what surgical procedures, what blocks and availability of a “block room”? Curr Opin Anaesthesiol 2022; 35:698-709. [PMID: 36302208 DOI: 10.1097/aco.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW With an expected rise in day care procedures with enhanced recovery programs, the use of specific regional anaesthesia can be useful. In this review, we will provide insight in the used regional block and medication so far known and its applicability in a day care setting. RECENT FINDINGS Regional anaesthesia has been improved with the aid of ultrasound-guided placement. However, it is not commonly used in the outpatient setting. Old, short acting local anaesthetics have found a second life and may be especially beneficial in the ambulatory setting replacing more long-acting local anaesthetics such as bupivacaine.To improve efficiency, a dedicated block room may facilitate the performance of regional anaesthesia. However, cost-efficacy for improved operating time, patient care and hospital efficiency has to be established. SUMMARY Regional anaesthesia has proven to be beneficial in ambulatory setting. Several short acting local anaesthetics are favourable over bupivacaine in the day care surgery. And if available, there are reports of the benefit of an additional block room used in a parallel (monitored) care of patients.
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Kim LS, Park T, Berger ER, Golshan M, Greenup RA. Editorial Comment on: One-Year Experience of Same-Day Mastectomy and Breast Reconstruction Protocol. Ann Surg Oncol 2022; 29:5361-5363. [PMID: 35834143 PMCID: PMC9281278 DOI: 10.1245/s10434-022-12021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/02/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Leah S Kim
- Department of Surgery, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Tristen Park
- Department of Surgery, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Elizabeth R Berger
- Department of Surgery, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Mehra Golshan
- Department of Surgery, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Rachel A Greenup
- Department of Surgery, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT, USA.
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Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4448. [PMID: 35924002 PMCID: PMC9298472 DOI: 10.1097/gox.0000000000004448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
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The Quest for Outpatient Mastectomy in COVID-19 Era: Barriers and Facilitators. Breast J 2022; 2022:1863519. [PMID: 35711886 PMCID: PMC9186523 DOI: 10.1155/2022/1863519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/16/2022] [Indexed: 12/04/2022]
Abstract
Background The rate of inpatient mastectomies remains high despite multiple studies reporting favourably on outpatient mastectomies. Outpatient mastectomies do not compromise quality of patient care and are more efficient than inpatient care. The objective of this study was to evaluate the feasibility of outpatient mastectomy. Materials and Methods Implementation of an outpatient mastectomy program was evaluated in a retrospective study. All patients who underwent mastectomy between January 2019 and September 2021 were included. Results 213 patients were enrolled in the study: 62.4% (n = 133) outpatient mastectomies versus 37.6% (n = 80) inpatient mastectomies. A steady rise in outpatient mastectomies was observed over time. The second quarter of 2020, coinciding with the first COVID-19 wave, showed a peak in outpatient mastectomies. The only significant barrier to outpatient mastectomy proved to be bilateral mastectomy. Unplanned return to care was observed in 27.8% of the outpatient versus 36.3% of the inpatient mastectomies (P=0.198); the reason for unplanned return of care was similar in both groups. Conclusions Outpatient mastectomy is shown to be feasible and safe with a steady increase during the study period. A barrier to outpatient mastectomy was bilateral mastectomy. Incidence of unplanned return to care or complications did not differ significantly between the outpatient and inpatient cohorts.
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Ludwig K, Wexelman B, Chen S, Cheng G, DeSnyder S, Golesorkhi N, Greenup R, James T, Lee B, Pockaj B, Vuong B, Fluharty S, Fuentes E, Rao R. Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group. Ann Surg Oncol 2022; 29:5799-5808. [PMID: 35503389 DOI: 10.1245/s10434-022-11799-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/07/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM). METHODS The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation. RESULTS Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities. CONCLUSIONS Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.
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Affiliation(s)
- Kandice Ludwig
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | - Gloria Cheng
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Ted James
- Harvard Medical School, Boston, MA, USA
| | | | | | - Brooke Vuong
- Kaiser Permanente Medical Center, Sacramento, CA, USA
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Ellsworth BL, Metz AK, Mott NM, Kazemi R, Stover M, Hughes T, Dossett LA. Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care. Ann Surg Oncol 2022; 29:3750-3762. [DOI: 10.1245/s10434-021-11303-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/18/2021] [Indexed: 12/28/2022]
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